The Surgical Dilemma of the MalunitedCalcaneal Joint Depression Fracture:The VAMC Miami Experience

During the period of October 1985 through March 1995,25 patients presented to the Veterans AffairsMedical Center, Miami with a chief complaint of chron ic pain status post calcaneal joint depressionfracture. Their acute injury was treated conservatively at this and various other institutions. Nine patientswere managed conservatively with orthotics, University of California Biomechanics Laboratory braces(UCBLs), shoe modification, or prosthetics. Sixteen patients underwent hindfoot fusions. Good toexcellent results were obtained in 15 of the 16 fusions. The remaining patient, having an isolatedsubtalar fusion, was later diagnosed with multiple sclerosis. Proper evaluation of the chronic painpatient is critical when mapping out an appropriate treatment plan. Hindfoot arthrodesis with soft tissuedecompression is a successful tool in eliminating chronic pain due to malunited depression fractures.(The Journal of Foot and Ankle Surgery 35(2):134-143, 1996)

Key words : calcaneal fracture; rearfoot malunion

Michael Cohen, DPM, FACFAS

Hstorically, the calcaneal joint depression fracture isone that has plagued the treating physician for manyyears. The literature is abundant with articles describingits treatment. Although they account for only 2.6 of allbody fractures, they are nevertheless responsible for60% of major tarsal injuries (1). Yet, what frustrates thefoot specialist is the large percentage of patients withunresolving pain regardless of the initial treatment mea­sures. This point is especially delivered by Nade et al.,who reported that 20% of patients with calcaneal frac­tures may be incapacitated up to 3 years postinjury, andmany are still incapacitated up to 5 years postinjury (2).When considering these statistics the economic implica­tions become obvious. Therefore, it is imperative thatthe physician properly assess and treat the sequela ofthis disabling injury. This article is an attempt to conveythe experience of the VAMC, Miami, and describe thepathologies involved in facilitating assessment and treat­ment of chronic pain patients.

Treatment of the malunited calcaneal joint depressionfracture is challenging to the surgeon. Pain in the heelfollowing fracture may encompass one or many factorson which treatment must be directed. Tendon pathologyparticularly involving the peroneals is one consequence

Diplomate , American Boards of Podiatri c Surgery and Podiatri cOrthopedics; Chief, Podiatry Service and Director , Podiatry Surg icalResidency Program. Address correspondence to: Veterans Affair sMedical Center (I l2D), 1201 NW 16th St., Miami, FL 33125.The Journal of Foot and Ankle Surgery 1067-2516/96/3502-0134$3.00/0Copyright © 1996 by the American College of Foot and AnkleSurgeons

that usually results from a distortion of the lateralcalcaneal wall. In this instance, the wider os calcis haslost its topographical anatomy resulting in the obstruc­tion of the peroneal gliding mechanism. Often theperoneals will slip within the widened subtalar joint orget compressed against the fibula . Damage to its reti ­nacular complex will result in scarring, compoundingperoneal obstruction, and inflicting focal vascular dam­age. Likewise, flexor hallucis longus impingement mustbe investigated. Tendon pathology may involve entrap­ment resulting in hypertrophy, tenosynovitis , partialtears, and intratendinous lesions. The structural distor­tion of the calcaneus will make proper shoe fit difficultdue to the loss of height and increased width, alteringthe axis of the subtalar joint. Intra-articular degenera­tion is a result of joint incongruity, primarily affectingthe subtalar and calcaneocuboid joints. Secondary in­volvement of the talonavicular and ankle joints mayoccur as a result of their compensatory mechanism.Finally, paresthesia involving the pericalcaneal nervesshould be investigated as this may result in neurologicalsymptoms, sometimes mimicking other types of patho­logical processes.

Initially, many of these postinjury derangements areattended to through conservative means. The chronicpain experienced is extremely variable and unpredict­able . In fact, the degree of pain reported by the patientis not always related to the degree of damage evidencedby radiography. Although severe disfigurement may benoted of the calcaneus radiographically, the disabilityencountered may be minimal due to an adequately

134 THE JOURNAL OF FOOT AND ANKLE SURGERY

functioning heel bone. A typical scenario involves aminimally displaced joint depression fracture, which,although not grossly distorted, possesses enough resid­ual subtalar joint movement to induce acute pain. Con­versely, a severely comminuted calcaneal fracture with amaximally displaced facet may pose very little discom­fort. The reasons for this observation are debatable, butappear to be related to the degree of function andsubtalar arthritis present (3).

Due to the multiple possible etiologies which can causechronic pain, proper evaluation of the post-fracture patientis mandatory for successful treatment. Consequently, ifproperly assessed, misdiagnosis is avoided. The authordivides the chronic pain patient into three basic etiologies,each with its own set of characteristic symptoms. Theetiologies may be divided into intra-articular, extra-articu­lar, or a combination of the two structural abnormalities.Using these three criterion, assessment of the chronic painpatient is more accurately obtained.

Intra-articular Pathology

Subtalar joint dysfunction results in loss of stance phaseimpact absorption. Torsional translation of the lower leg istransferred to the ankle and transverse tarsus. Intra-artic­ular pathology may, therefore, be a result of degenerationin any of the tritarsal articulations of the hindfoot. This canbe effectively isolated and ruled out by using appropriateimaging techniques consisting of radiographs, computer­ized tomography (CT) scans, magnetic resonance imaging(MRI), and careful clinical evaluation, often requiringselective diagnostic blockade .

Initially,patients with acute intra-articular symptomatol­ogy will often complain of inframalleolar pain that ispresent particularly laterally. They will usually point to thesinus tarsi and distal fibular tip. The pain will frequentlyradiate posteriorly and inferiorly to the base of the tuber.The acute subastragalar pain begins to diminish slowlyafter a 6- to 8-month period. However, some authors havereported improvement anywhere from 2 to 10years (4-6).The author's observation indicates that after 6 to 8 monthsthe discomfort is inversely proportional to the subtalarrange of motion and decreases with stiffening or ankylosisof the joint. In fact, according to Jaekle et aL, it is ultimatelythe subastragalar arthritis pain that is the leading cause ofdisability after calcaneal fractures (7). Eighty-nine percentof intra-articular fractures result in a decreased range ofmotion (8). On the other hand , it has been reported thatneither the degree of subtalar joint stiffness nor the radio­graphic evidence of degenerative joint disease correspondsaccurately to the symptomatology (9). Much like Slatis etal., the author has found that subtalar joint limitation hasbeen universal, whether or not aggressive range of motionexercises were administered (8).

After 6 to 8 months subtalar joint pain slowly convertsfrom acute to chronic, presenting itself as a dull , achingfatigue , present especially following more extensiveweight bearing. At this point, the symptomatic subtalarjoint has usually become incompletely ankylosed (subta­lar limitus), allowing enough micro movement to con­tinue inciting a pain response. Limitation will result incompensation that is translated distally to the transversetarsus, and often elicits periarticular reactive bone for­mation much like the compensatory changes observedwith subtalar coalition. This periarticular bone is not tobe confused with degenerative joint disease which exhib­its a different pathology altogether, and, therefore, itspresence should not alarm the surgeon, as an arthrodesismay not necessarily be warranted (10, 11).

The rigid subtalar joint is frequently the joint that isasymptomatic due to complete ankylosis and most oftenwill not require surgical attention, particularly if thehealed calcaneus is in acceptable alignment. Interest­ingly, this observation contradicts attempts to obtainimmediate subtalar joint range of motion post injury.Conservative treatment of subtalar joint symptomatol­ogy at the Miami VA Medical Center focuses on limi­tation of frontal plane motion through the use ofstrapping, ankle foot orthoses, University of CaliforniaBiomechanics Laboratory braces (UCBLs), flat postedorthotics, or high-top shoe gear. Intra-articular injec­tions with corticosteroids are self-limiting and shouldonly be used to control acute pain. The use of nonste­roidal anti-inflammatories has achieved variable successin obtaining pain relief. Intra-articular derangement inany of the transverse tarsal articulations needs to beruled out in order to implement a definitive surgicalattack. This can be accomplished effectively with the useof selective intra-articular blockade. A positive findingwill warrant triple arthrodesis, particularly in light offailed conservative treatment.

The author has found that ankle symptomatology postcalcaneal fracture has been mild to nonexistent, partic­ularly when fusion or ankylosis of the subtalar joint hasdemanded minimal frontal plane hypermobility. This isnot surprising, however, in light of the low incidence ofsymptomatic ankle arthrosis, status post triple arthrode­sis (11, 12). When symptomatic, rearfoot malalignmentmay be treated conservatively with the use of variousprosthetics. Otherwise surgical reconstruction will usu­ally relieve symptoms in the ankle by obviating its needto compensate for a distorted hindfoot.

Extra-articular Pathology

When symptomatology is related to extra-articularfactors, it should be dealt with accordingly. One consis­tent complaint observed is a "sharp, stabbing" pain at

VOLUME 35, NUMBER 2, 1996 135

the base of the heel. The author believes that itsexistence is due to stretching of the plantar fascia whichoccurs as a result of a drop in calcaneal pitch causing alengthening of the medial arch, and pronation of thefoot. This structural distortion consequently mimics thepathomechanics of heel spur syndrome. The sharp paineventually dissipates with time and may be treatedconservatively with appropriate orthosis, physical ther­apy, and infracalcaneal steroid injections after fracturehealing.

Furthermore, the loss of calcaneal pitch will result ina loss of mechanical leverage of the triceps surae. Thedrop in calcaneal pitch, together with a mal-positionedposterior facet, results in the limitation of motion in thetransverse tarsus due to a "double cam" mechanism(13). This point is especially appreciated when oneconsiders the intimate relationship between the twojoints in the midtarsal complex. Furthermore, the reduc­tion in calcaneal pitch makes shoe fit difficult due tofibular abutment on the lateral heel counter, and be­cause of the loss in height, the affected limb mayultimately function as a shortened extremity. Conserva­tive therapy includes application of a heel lift, obtainingshoes with a wider heel counter, or orthotics prescribedwith the necessary modifications. Reconstructive surgerymust focus on restructuring the true vertical pitch of theos calcis , often requiring extensive bone grafting, orosteotomy of the calcaneus.

Tendon pathology must be examined carefully as it isoccasionally mistaken for intra-articular discomfort.Proper clinical and radiographic analysis are essential inassessing the etiology and extent of damage sustained tothe peroneal retinacular channels, and the lateral wall ofthe calcaneus, of which the peroneals are intimatelyassociated. Conservative therapy once again revolvesaround limitation of excessive motion in the ankle andsubtalar complex in an effort to reduce irritation. Recal­citrant pain will mandate surgical decompression of theperoneals, debulking of the lateral calcaneal wall byeliminating any prominences responsible for impinge­ment, and re-establishing the peroneal glide mecha­nisms. Additionally, synovectomy is indicated if hemor­rhaging and synovitis are suspected. These proceduresare usually performed ancillary to other more definitiveosseous procedures.

Lateral decompression has been described in variousways in the literature. Braly et ai. reported on a methodof decompression that allowed access to the sural nerveand peroneal tendons through a lateral incision (14). Inthis procedure neurolysis was performed as well asperoneal tendolysis and "Z" lengthening. The calcaneo­fibular ligament was sectioned to allow relocation andrepaired. Lateral calcaneal ostectomy was executed torelieve encroachment and fibular abutment. Isbister

recognized the calcaneofibular abutment syndrome as adistinct sequela of the crushed heel (15). His surgicalapproach involved resection of the lower 1 em. of thefibula. Tendon abnormalities involving the flexor com­partment musculature are addressed similarly. Paresthe­sia may indicate posterior tibial or sural nerve involve­ment either through perineural fibrosis, impingement,and, although not often, transection. Interestingly,Guillen et al. reported that when reviewing 56 cases,10% of patients with calcaneal fractures presented withclinical signs of tarsal tunnel syndrome (16).

Although reportedly successful in the literature by afew (17, 18), the temptation to perform primary arthro­desis in the immediate postinjury state is not advisable.The unstable infrastructure and compromised vascular­ity of the os calcis makes the surgical outcome unpre­dictable. Therefore, arthrodesis should be reserved as anend-stage salvage procedure. Additionally, postponingarthrodesis and instituting primary reduction at the timeof injury will allow the surgeon and patient to see ifsymptomatology can be avoided altogether with properprimary fracture reduction. Likewise, this strategy willimprove bone consistency, thereby furnishing a favor­able groundwork for future surgical reconstruction, if infact it is required.

Diagnostic Imaging and Laboratory Studies

Proper evaluation of the chronic patient requires acomplete radiographic analysis. Successful treatmentrevolves around the appropriate correlation of the pa­tient's history to radiographic findings. Views orderedinclude anterior to posterior (AP), medial oblique(MO), and lateral of the foot in weight bearing attitude,AP, mortise, Broden views of the ankle, and a calcanealaxial (19). Broden views are made by placing the x-rayplate behind the ankle and foot and then internallyrotating the foot so that the malleoli are parallel to theplate. The beam is then centered on the subtalar jointand angled caudal cephalad 10°, 20°, 30°, 40°, and 50°from vertical. This allows sequential imaging of theposterior facet split and differential depression illus­trated.

As in the acute fracture, CT scanning is indispensablein assessing the subtalar joint, evaluating topographicderangement, particularly the calcaneal pitch, and estab­lishing the integrity of the bone which will anticipatefixation and osteotomy placement should surgery beinitiated. CT scanning will also provide the surgeon withsome insight regarding the disposition of the transversetarsal joints.

Tendon pathology may be evaluated through tenog­raphy, ultrasonography, or MRI (20). Radiographs andCT scanning will aid in ruling out bony etiology. Never-

136 THE JOURNAL OF FOOT AND ANKLE SURGERY

TABLE 1 Objectives of surgery

1. Re-establishing verticality of the os calcls with relocation ofproper medial column axis.

2. Debulking of the lateral calcaneal wall.3. Selective arthrodesis of the hindfoot.4. Decompression of medial or lateral tendon encroachment.5. Appropriate nerve releases or excision.

theless, the author has found clinical evidence sufficientin most cases for diagnosing tendon pathology. Neuro­pathology may be evaluated clinically. This may presentitself with neuromatous or tarsal tunnel like symptomsoccasionally requiring local nerve blocks for properassessment. Electromyogram (EMG) and nerve conduc­tion velocity (NCV) studies may be obtained if theposterior tibial nerve status is in question, and MRI canbe reserved to help rule out adhesions or gross nervedistortion in any of the pericalcaneal nerves.

Surgical Reconstruction of the MalunitedCalcaneal Joint Depression Fracture

Reconstructive surgery must be considered in theevent conservative therapy fails, thereby compromisingthe quality of life. As with the acute patient, chronicfracture patients must be critically assessed preopera­tively, while various objectives should come to mindwhen mapping out a surgical strategy (Table 1).

Selective arthrodesis of the subtalar joint (STJ) versustriple arthrodesis is a decision a surgeon must face whenattempting reconstruction. Debulking the calcaneus andre-establishing pitch may be accomplished simulta­neously. The author prefers to fuse the transverse tarsusin cases where secondary degenerative changes co-exist.This decision can be made clinically and can be aug­mented with radiographs, CT scanning, and carefulintraoperative assessment. Arthrodesis of the subtalarjoint has been recommended in lieu of triple arthrodesis,provided that the calcaneocuboid and talonavicularjoints are free of distortion (16, 21).

Fusion of the subtalar joint can present as a chal­lenge to the surgeon due to the distorted topographyof the calcaneus. One must attempt to re-establish theheight and width of the calcaneus when designing thesurgical approach. Essentially, pitch can be recon­structed in two ways, the methods available involveeither osteotomy or bone grafting of the defect.Romash described a technique in which the primaryfracture was recreated and shifted accordingly (22).This technique reduced the width and elevated theheight of the heel bone. The subtalar joint is simulta­neously arthrodesed with a laterally placed bone graft.The method used by the author involves clearing thesubtalar joint and re-establishing pitch with the inser-

FIGURE 1 Artist's rendition of axial calcaneal views indicating (A)preoperative projection with widened heel and subtalar arthritis,with the dotted line indicating area to be debulked and decom­pressed, and (B) position of bone graft and screw for arthrodesis.

tion of an allogenic corticocancellous bone graft. Thegraft is transfixed to the calcaneus and talus with a6.5- or 7.0-mm. cortical screw. Heel widening andlateral impingement is attended to with debulking ofthe lateral blowout (Fig. 1).

Technique

Fusion of the subtalar joint is performed through astandard lateral modified Ollier'sl incision which isdeepened to the extensor digitorum brevis musclebelly (EDB), with care being taken to identify andretract the sural nerve and lesser saphenous vein. Thecourse of the sural nerve is carefully traced andinspected for pathology. The EDB is detached andelevated with the subcutaneous tissue and skin as oneflap. This maneuver exposes the calcaneocuboid joint.The sinus tarsi is evacuated to expose the middlecalcaneal facet. Further dissection plantarly and pos­teriorly reveal the peroneal complex which is carefullyinspected for abnormalities and retracted. The peri­osteal layer, which is usually scarified, is dissectedaway from the lateral calcaneal wall. If possible, thesubtalar joint is forcefully inverted and visualized. Inmost cases, the joint may be ankylosed and concealeddue to impaction, making it difficult to identify. In thisinstance, the peroneal retinaculum, along with thecalcaneofibular ligament, must be transected in orderto allow superior retraction of the peroneals and toprovide room for joint exposure.

1 An incision placed posterior and parallel to the fibular malleolusand curving anterior-distal to the sinus tarsi.

VOLUME 35, NUMBER 2, 1996 137

An osteotome or elevator is used to demarcate the levelof the joint that is decompressed and evacuated of allfibrous scar tissue. The remaining defect is inspected, andsubtalar decompression is performed until bleeding boneappears. At this time, debulking of the lateral calcanealwall is performed with an osteotome or sagittal saw, ifrequired. A laminar spreader is inserted into the void andexpanded aptly to re-establish pitch. An appropriatelyfashioned corticocancellous freeze-dried bone graft isplaced into the subtalar defect and rigidly fixated (Fig. 1).Particular attention is given to the talonavicular axis whensculpturing the bone graft, thereby assuring proper medialcolumn stability while simultaneously maintaining the heelwithin approximately 5° of valgus. The author prefers theuse of a 7.0-mm. cannulated screw placed from the lateralinferior posterior calcaneus, cephalad through the subtalarjoint, and grasping the talar neck. This approach is madewith one plantar posterior stab incision and usually di­rected with the aid of fluoroscopy. The advantages over anapproach made through the superior dorsal medial talarneck to the inferior calcaneus are many. Penetration anddissection of the ankle joint is avoided. This is particularlytrue if removal of hardware is required after fusion isaccomplished. Furthermore, anterior tibial impingementagainst the screw head is avoided. Finally, when consider­ing compromised bone density (particularly in instanceswhere the calcaneus appears cystic or irregular as wit-

FIGURE 2 Pre- and postoperative lateral views (A, B) of subtalarjoint fusion without bone grafting. This patient had no evidence ofdegenerative changes in the transverse tarsus.

FIGURE 3 Pre- and postoperative lateral views (A, B) of subtalarjoint fusion utilizing a 7.0-mm. cannulated screw, employing aplantar distal oblique entry with the assistance of fluoroscopy.

nessed on cr or radiographs), the screw threads willmaintain a superior grab due to the presence of healthycortical bone in the neck of the talus (Figs. 2-6).

With the subtalar joint rigidly fixated, attention isdirected to the peroneal tendons whereby any tendonpathology may be noted and attended to, as discussedpreviously. If the anterior fracture line exited throughthe calcaneocuboid (CC) joint implicating degenerativejoint disease (DJD), or in instances where compensatorydeterioration of the transverse tarsus is observed, fusionof Chopart's joint is indicated and instituted usingstandard triple arthrodesis technique. Proper heel align­ment during subtalar fusion obviates wedge resectionaltriple arthrodesis, unless pre-existing pathology so dic­tates (Figs. 3-6).

Postoperative care requires the application of a shortleg non-weight bearing cast for approximately 8 to 12weeks depending on whether bone grafting has beenemployed. The cast is bivalved at 2 to 3 weeks postop­eratively whereby ankle range of motion exercises arebegun. Partial weight bearing is instituted at approxi-

138 THE JOURNAL OF FOOT AND ANKLE SURGERY

FIGURE 4 Case 6: A 46-year-oldwhite male who sustained a calcanealjoint depression fracture while servingas a veteran in Vietnam. The patientreported severe pain during ambulationthat increased in intensity with activity.Preoperative lateral and axial views (A,B) are consistent with healed calcanealfracture and subtalar arthritis (note wid­ened heel with hypertrophic peronealtrochlea). C and 0 represent postoper­ative views of triple arthrodesis (AP,LAT).

mately 10 weeks. Initially, this may require the use of apatellar tendon bearing (PTB) cast prior to partialweight bearing with the use of a short leg weight bearingcast. Partial bearing of weight is altered to a full weightbearing cast or walker until radiographic signs of con­solidation are noted. At this point, the cast is removedand a polypropylene posterior leaf spring ankle footorthosis or UCBL is dispensed and worn from 1 to 3months. Otherwise the patient is fitted postoperativelywith definitive treatment consisting of flat posted ortho­sis, UCBL, or molded shoes.

Materials and Methods

During the period of October 1985 through March1995, 25 patients presented to the Veterans Affairs

Medical Center, Miami, with a chief complaint ofchronic pain status post calcaneal joint depressionfracture. Nine of them had their acute fracturestreated conservatively with immobilization. Open re­duction was precluded due to age, medical disease,psychiatric conditions, or failure to give surgical con­sent. Additionally, 16 patients presented with chronichindfoot pain after joint depression fractures hadbeen conservatively treated elsewhere. Of the 25patients who presented to the clinic, 9 were treatedconservatively with various prosthetics and shoe mod­ifications, of which 4 patients remained acutely symp­tomatic. These 4 patients were inoperable due toreasons listed above. The remaining 16 underwenthindfoot arthrodesis.

VOLUME 35, NUMBER 2, 1996 139

FIGURE 5 Case 7: A 66-year-old noninsulin-dependent diabetes mellitus male presents 7 years post joint depression fracture. PreoperativeCT scan (A) illustrates severe subtalar degeneration and altered calcaneal morphology, with evidence of fracture extending to the CC joint.Preoperative Broden I view reveals subtalar derangement (B). Postoperative lateral (C) and axial (0) views reveal triple arthrodesis withsubtalar bone grafting (dotted lines) and debridement of lateral wall.

140 THE JOURNAL OF FOOT AND ANKLE SURGERY

FIGURE 5 (continued) .

In order to assess the surgical success rate, the resultsof the arthrodesis procedure were classified objectivelyby the surgeon using the following four criterion: excel­lent , good, fair , and poor. Patients who obtained anexcellent result were those who were able to return totheir preinjury activities with minimal to no limitationsdue to pain, and did not require postoperative prostheticcare to achieve painless ambulation. This includes thepermanent use of ankle/foot orthoses, canes, crutches,or special shoe gear. These patients rarely required theuse of nonsteroidal anti-inflammatory drugs, and wereable to return to employment without request for per­manent disability. Patients with good results had minorlimitations compared to preinjury activities. These pa­tients required postoperative orthotic assistance in orderto achieve pain free ambulation, although other pros­thetic devices were not needed. This group has requiredthe occasional use of NSAIDs (not narcotics), for paincontrol. They experienced minor dull pain after ex­tended exertion, but were able to return to employmentwithout request for disability. Patients in this categorywere able to return to their preinjury activities withminor alteration in lifestyle. Patients in the fair categoryreported an inability to return to most of their pre injuryactivities , experienced mild to moderate pain , and re­quired the use of NSAIDs for analgesia. The amount ofpain and its severity was dependent upon the amount ofexertion (i.e., distance, physical activity, etc.). Addition-

ally, this group of patients was able to return to employ­ment with modifications or minor permanent restric­tions in their preinjury employment requirements.Patients in the poor category consisted of patients withmoderate to severe pain. These patients were completelydependent on prosthetic devices. This group had under­gone extensive postoperative physical therapy, yet stillneeded the assistance of a crutch or cane. The patientsin this group frequently requested narcotic analgesics,and would not return to preinjury employment withoutsevere restrictions in activity. They were considered tohave an unsatisfactory result.

Results

In this study, out of the 25 chronic pain patients whopresented to the VAMC, Miami, 64% (16) underwenthindfoot arthrodesis. Out of the 16 total rearfoot arthro­deses performed, 75% (12) reported excellent results, 10 ofwhich were triple arthrodesis, 19% (3) reported goodresults, one of which was a triple arthrodesis and 6% (1)with poor results (Fig. 7). There were no cases of nonunioneven though extensive bone grafting was necessary in twopatients. There was a minor lateral wound dehiscence inone patient which was successfullytreated with local woundcare. Ten of the sixteen patients underwent simultaneousdebulking of the lateral wall. Ten of the sixteen patientswere noted to have peroneal tendon aberration consisting

VOLUME 35, NUMBER 2, 1996 141

FIGURE 6 Case 8: A 58-year-old Hispanic male customs officer. The patient had fallen while attempting to make repairs on the roof of hishouse 18 months previously. Preoperative lateral (A) and medial oblique (8) views indicate a subtalar joint depression fracture with loss ofheight and distortion of the talar pitch. The patient indicated pain along the plantar aspect of the heel and sinus tarsi. Postoperative lateral(C) and medial oblique (0) views demonstrate triple arthrodesis with freeze-dried bone grafting (arrows) restoring height and pitch. Fixationwas executed using a 7.0-mm. cannulated screw and blount staples.

of synovitis, atrophy, adhesions, and partial tear, all ofwhich were attended to appropriately using the techniquedescribed. Bone grafting was employed in 15 fusions, allwere within the subtalar joint. Eight of the grafted jointsconsisted of allogenic corticocancellous bone. Eleven un­derwent triple arthrodesis and the remaining five hadundergone isolated subtalar joint fusions. Four of thesubtalar fusions reported excellent results, while the re­maining patient was placed in the poor category. Thispatient was a 32-year-old white female who was laterdiagnosed with multiple sclerosis. Alternatively an inciden­tal finding revealed that only 55% of patients who weretreated conservatively reported marked improvement insymptoms.

Discussion

Hindfoot fusion with soft tissue decompression issuccessful, particularly when restoration of proper cal-

caneal pitch and medial column architecture is main­tained. Again, proper patient selection along with selec­tive joint arthrodesis is of utmost importance in avoidinguntoward results. It must be understood that arthrodesis

75%Excellen t

FIGURE 7 Results of 16 patients who were treated with hindfootfusion.

142 THE JOURNAL OF FOOT AND ANKLE SURGERY

is a salvage procedure. The indications must be diag­nosed properly, especially in the event that a decompres­sion or isolated fusion procedure is being entertainedrather than a tritarsal oblation. Comparatively, conser­vative care patients did not fare as well, although acomparison was not the objective of this study.

Summary

Treatment of the malunited calcaneal joint depressionfracture poses a challenge to the reconstructive foot sur­geon. The debilitating elements must be precisely pin­pointed in order to effect the proper treatment. This mayinclude hindfoot fusion, calcaneal debridement, tendondecompression, and nerve excision or releases. One factornot mentioned yet as a causative agent of chronic pain isthe calcaneal fat pad. Miller (23) theorized that a majorcomponent of recalcitrant subcalcaneal pain followingfrac­ture was due to an irreversible derangement of the "U­shaped" fibrous septa that maintain the pistoning charac­teristic of the plantar fat pad. He went on further to discussa mammographic technique for imaging the heel pad forrecalcitrant heel pain. However, a recent study by Levy etal. utilized magnetic resonance imaging to evaluate thecalcaneal fat pad in patients who are status post os calcisfractures (24). Utilizing a superiorly detailed visualizationtechnique, no evidence was found to support the sugges­tion that damage to the gross structure of the fat pad hadoccurred at the time of injury. Hence, no data was foundsuggesting that chronic pain was related to fat pad struc­ture. The MRI studies indicated that marked swelling inthe pad after acute injury was in fact due to the opening ofthe fat pad at its margins rather than intracolumn fat padchanges. Therefore, anatomic reduction should theoreti­cally allow the pad margins to return to their originaldimensions. It is the author's belief that subcalcaneal painfollowing fractures is in fact related to the drop in calcanealpitch, thereby producing tension on the plantar fascia. Thisincrease in tension ultimately produces stress on the fasciabone interface resulting in symptomatology similar to heelspur syndrome. As such, treatment may be directed in thismanner.

When investigating the results of arthrodesis proce­dures, 94% fell into the excellent and good categories.This finding indicates that, as a salvage procedure,arthrodesis is effective in relieving pain and producingmarked improvement in the activities of daily living.However, satisfactory results with conservative treat­ment of the chronic pain patient were not as apparent. Itis imperative to note that the median age in this studywas 58 years. Many of these patients consisted of apopulation segment that is relatively sedentary whencompared to their younger counterparts.

Although complicated, proper assessment of the mal-

united calcaneal depression fracture is crucial in obtain­ing a successful treatment outcome. The physician musttherefore carefully evaluate the intra-articular, extra­articular, or combination of pathologies involved. Whenproperly assessed, the surgeon can then correctly choosebetween his conservative and surgical regimens.

References

1. Cave, E. F. Fractures ofthe os calcis, the problem in general. Clin.Orthop. 30:64-66, 1963.

2. Nade, S. M. L., Monahan, P. R. W. Fractures of the calcaneum, astudy of the long term prognosis. Injury 4:200-207, 1973.

3. James, E. T. R, Hunter, G. A. The dilemma of painful old os calcisfractures. Clin. Orthop. 177:112-115, 1983.

4. Essex-Lopressti, P. The mechanism, reduction technique, andresults in fractures of the os calcis. Br. J. Surg. 39:395-419, 1952.

5. Gage, J. R, Premer, R Os calcis fractures, an analysis of 37. Minn.Med. 54:169-176, 1971.

6. Lindsay, W. R N., Dewar, F. P. Fractures of the calcaneum. Am.J. Surg. 95:555-576, 1958.

7. Jaekle, R S., Clark, A. G. Fractures of the os calcis. Surg. Gynecol.Obstet. 64:663-672, 1937.

8. Slatis, P. K., Kiviluoto, 0., Santavirtas, S. Fractures of the calca­neum. J. Trauma 19:939-943, 1979.

9. Pozo, J. L., Kirwan, E. O. G., Jackson, A. M. The long term resultsof conservative management of severely displaced fractures of thecalcaneus. J. Bone Joint Surg. 66B:386-390, 1984.

10. Johnson, M. K, Kanat, I. O. Complications of triple arthrodesis withcomparison to select rearfoot fusions. J. Foot Surg. 26:371-379, 1987.

11. Kaplan, E. G., Kaplan, G. S. Triple arthrodesis. J. Foot Surg.15:93-98, 1976.

12. Pennal, G. F., Yadav, M. P. Operative treatment of comminutedfractures of the os calcis. Orthop. Clin, North Am. 4:197-211, 1973.

13. Romash, M. M. Calcaneal fractures: three dimensional treatment.Foot Ankle 8:180-197, 1988.

14. Braly, W. G., Bishop, J. 0., Tullos, H. S. Lateral decompressionfor malunited os calcis fractures. Foot Ankle 6:90-96, 1985.

15. Isbister, J. F. Calcaneofibular abutment following crush fracture ofthe calcaneus. J. Bone Joint Surg. 56B:274-278, 1974.

16. Leung, K. S., Yen, K. M., Chan, W. S. Operative treatment ofdisplaced intra-articular fractures of the calcaneum: medium-termresults. J. Bone Joint Surg. 75B:196-211, 1993.

17. Allan, J. H. The open reduction of fractures of the os calcis. Am.Surg. 141:890-900, 1955.

18. Skie, M. C, Zeiss, J., Ebraheim, R A., Jackson, W. T. Radiolog­ical evaluation of peroneal tendon pathology associated withcalcaneal fractures. J. Orthop. Trauma 5:365-69, 1991.

19. Broden, B. Roentgen examination of the subtaloid joint in frac-tures of the calcaneus. Acta Radiol. 31:85-91, 1949.

20. Miller, W. E. The heel pad. Am. J. Sports Med. 10:19-21, 1982.21. Bankart, A. S. B. Fractures of the calcis. Lancet 2:175,1942.22. Romash, M. Reconstructive osteotomy of the calcaneus with

subtalar arthrodesis for malunited calcaneal fractures. Clin. Or­thop. ReI. Res. 290:157-162, 1993.

23. Miller, W. E., Lichtblau, P. O. The smashed heel. South Med. J.58:1229-1237, 1965.

24. Levy, A. S., Berkowitz, R., Franklin, P., Corbett, M., Whitelaw,G. P. Magnetic resonance imaging evaluation of calcaneal fatpads in patients with os calcis fractures. Foot Ankle 13:57-62,1992.

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